Interposition arthroplasty with bovine collagenous membrane for hallux rigidus: A long-term results retrospective study.

BACKGROUND: Hallux rigidus (HR) is a degenerative arthritis of the first metatarsophalangeal joint (MTP1) with progressive loss of range of movement (ROM). Interposition arthroplasty (IA) is a technique widely used for the treatment of HR;however, few studies reported long-term clinical results. This study aims to report the clinical results of IA using a bovine pericardium collagen matrix for HR with a minimum 10-years follow-up. METHODS: Thirty patients (31 feet) who underwent IA using a bovine pericardium collagen matrix from 2001 to 2009 were retrospectively evaluated with a mean follow up of 154.1 ± 28.6 (range 124-218) months. All HR ranged from grade II to grade III, according to Regnauld classification. All patients were clinically assessed with the American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal- Interphalangeal Scale, a pain Visual Analog Scale, and the Foot and Ankle Disability Index. Scores before and after treatment, respectively achieved from clinical records and clinical evaluation at final follow-up were compared. RESULTS: At final follow-up, an improvement of all the considered scores (p < 0.01) was recorded. The overall rate of unsatisfying results was 16.1 %. Two (6.4 %) patients complained discomfort due to first ray shortening and 3 (9.7 %) cases of persistent metatarsal pain. There was one (3.2 %) case of Complex Regional Pain Syndrome (CPRS). No revision surgeries, infection, or other adverse events were reported. CONCLUSION: Interposition arthroplasty using bovine collagenous membrane is a reliable solution for high-grade HR with durable results over 10 years in more than 80 % of patients.

Could direct transdeltoid approach to severely displaced proximal humerus fracture be advantageous for a better reduction?

BACKGROUND: Surgical treatment of proximal humeral fractures (PHF) is a challenge for orthopaedic surgeons. Despite the wide application of open reduction and internal fixation with locking plates, the optimal surgical approach of PHF is still debated. This study aims to evaluate the radiological outcomes, defined as anatomical restoration of the greater tuberosity and humeral head-shaft angle, of the deltopectoral (DPA) and the lateral transdeltoid (LTA) approaches in three- and four-part PHF, treated with locking plate. MATERIALS AND METHODS: This retrospective series review identifies 74 PHF surgically treated between January 2012 and December 2019. Patients were divided into two groups according to the surgical approach (DPA vs LTA). Demographic data, duration of surgery, radiological pre- and post-surgery parameters (greater tuberosity displacement and humeral head-shaft angle) were collected. The association between the surgical approach and the quality of fractures reduction was assessed. RESULTS: The use of LTA approach correlates with a better reduction of greater tuberosity displacements compare to DPA (63% in DPA vs 100% LTA). No significant association was found with the humeral head-shaft angle (restored in 89% of the patients in DPA and 86% in LTA group), and surgical times (range 40 - 210 minutes ± DS 33,56 for the DPA; range 45 - 170 minutes ± 29,60 for LTA). CONCLUSIONS: The results of this radiological study suggest that PHF with significant displacement of the grater tuberosity could benefit from the adoption of a lateral transdeltoid approach for the ORIF procedure. Further studies are needed to confirm these findings.

Effectiveness of corticosteroid injections in Civinini-Morton's Syndrome: A systematic review.

BACKGROUND: The aim of this paper is to analyze the effectiveness of corticosteroid injections (CI), in combination with or without a local anaesthetic, for Civinini-Morton's Syndrome to determine which protocol could be the most appropriate among conservative treatments. METHODS: All selected articles were screened using a thorough database search of PubMed, EMBASE and SCOPUS to assess their suitability to the research focus. RESULTS: Selection produced 10 articles as full-text, for a total of 590 patients, with a mean follow-up of 14 ± 14.2 (range 3-48) months. Johnson satisfaction scale, resulting from 6 studies, scored 25.6% (range 5-38) and 39.4% (range 15-51.8), respectively completely satisfied and satisfied with minor reservations. Mean VAS, declared in 5 studies, decreased from 70.7 ± 16.5 (range 67-89) to 33.4 ± 7.6 (26-42.5) points (p < 0.01). Most common complication was skin depigmentation in 7 (2.6%) cases. CONCLUSIONS: CI appear to be a safe treatment allowing good results with a very low complications rate. A neuroma of 6.3 mm seems to be the cut-off size; below which CI could have best indications and be considered as an intermediate treatment between shoe modifications and more invasive procedures such as percutaneous alcoholization or surgery. LEVEL OF EVIDENCE: Level II, systematic review.

Thirty-Day Mortality in COVID-19 Positive Patients With Hip Fractures: A Case-Series and Literature Review.

INTRODUCTION: The novel coronavirus has spread rapidly around the world with particularly high mortality in the elderly. Care and nursing homes have become the sites of greatest concentration of cases. We intended to review 30-day mortality of COVID-19 patients with hip fractures. This is relevant given the disease impact in this age group. METHODS: Medline and Embase databases were searched for relevant studies linked to mortality and morbidity in COVID-19 patients who have undergone non-elective hip surgeries using the keywords "COVID-19"OR "SARS-cov-2"OR "Coronavirus Infections"; AND "Surgery"OR "Hip"OR "Fracture"OR "Orthopedics." We included all patients with hip fractures, but excluded pathological fractures and other non-traumatic hip pathologies. Four-hundred and eighty-one articles were identified for screening, in addition to an unpublished case-series of 67 patients that have 3 cases turned positive for COVID 19, yielding a total of 50patients for the final review. RESULTS: The study included 4 articles published until May 9th 2020 and a case-series: 26(52%) patients were females; the median age was 86years; hypertension(53.6%), diabetes mellitus type II(28.6%), and coronary artery heart disease(25%) were the most common comorbidities; 34(68%) patients had intertrochanteric hip fracture and 16(32%) patients had femoral neck fractures; 22(59.5%) patients underwent cephalomedullary nail fixation, 12(32.4%) patients had hemiarthroplasty, and for 3(8.1%) patients, the type of surgery was not documented; 20(40%) patients died(12patients died before the surgery and 8died after surgery at a median time of 3days), 29(76.3%) patients had an unremarkable course throughout hospitalization and were discharged including 1(2.6%) patient managed non-operatively, and 1(2.6%) patient was admitted to the ICU after the surgery but eventually discharged. CONCLUSION: COVID-19 infected elderly patients have a higher 30-days mortality rate compared to non-COVID-19 infected cases. Further studies are warranted to look at the morbidity and mortality rates in COVID-19 positive patients with hip fractures and to investigate how these outcomes can be improved. LEVEL OF EVIDENCE: Level IV.

The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art.

Civinini Morton's Syndrome (CMS), better known as Morton's Neuroma, is a benign enlargement that typically affects the third common digital branch of the plantar nerve. It is a common cause of metatarsalgia leading to debilitating pain. It prefers the female gender, with a female to male ratio of 5:1 and an average age of 50 years at time of surgery. Precise aetiology remains under debate, with four etiopathogenetic theories often cited in the literature. Clinical symptoms, physical exam and instrumental evidence are important in assessing and grading the disease. Biomechanics seem to play an important role, especially regarding the usefulness of correct footwear. The first approach in the early stages of this condition usually begins with shoe modifications and orthotics, designed to limit the nerve compression. In order to prevent or delay the development of CMS, shoes should be sufficiently long, comfortable, broad toe-boxed, should bear a flat heel and a sufficiently thick external sole which should not be excessively flexible. Most authors suggested that an insole with medial arch support and a retrocapital bar or pad, just proximal to the metatarsal heads, displaces the pressure sites and can be beneficial to relieve the pain from the pinched nerve. A threshold period of 4.5 months appears to emerge from the results of the analysed studies, indicating that, beyond this period and in neuromas larger than 5-6 mm, orthotics and/or shoes modifications do not seem to give convincing results, proving to be more a palliation for the clinical condition to allow an acceptable life with pain rather than a real treatment.

Improved Injection Technique of Ethanol for Morton's Neuroma.

BACKGROUND: Morton's neuroma is a common cause of forefoot pain. Various conservative methods (injections of various pharmacologic agents) have been published with an outcome of 6%-75% success rate (free of pain in daily life) per injection. The aim of the present study was to assess the outcome of an improved localization technique, a higher dosage, and a higher percentage of ethanol. METHODS: Using fluoroscopic and electroneurographic guidance, 2.5 mL of 70% ethanol were injected into 33 feet with a magnetic resonance imaging (MRI)-verified neuroma. We evaluated patients at up to 5-year follow-up. RESULTS: A "success rate" of more than 82% per single injection (defined as free of pain in daily life) was achieved and no recurrence was seen over 5 years. All scores (visual analog scale; Short Form-36 subscales, American Orthopaedic Foot & Ankle Society ankle-hindfoot score) showed significant improvement (P < .0001). Mean 1.2 injections were necessary. No significant side effects were seen. However, some mild pain persisted in some patients who participated in sports. CONCLUSION: The injection of 2.5 mL of 70% ethanol under fluoroscopic and electroneurographic guidance was a safe method for the treatment of MRI-verified Morton's neuromas. Combining the effect of a higher percentage of alcohol and a higher dosage and an improved localization technique resulted in a high rate of patients without pain. LEVEL OF EVIDENCE: Level IV, cases series, prospective.

Can percutaneous alcoholization of Morton's neuroma with phenol by electrostimulation guidance be an alternative to surgical excision? Long-term results.

BACKGROUND: Percutaneous alcoholization with phenol by electrostimulation guidance for the treatment of Morton's neuroma is proposed to determine a permanent chemical neurolysis. METHODS: 115 patients for 125 Morton's neuromas were treated. Ten patients were affected by multiple neuromas. Visual Analogue Scale and AOFAS score were used for the clinical assessment. RESULTS: The mean follow-up was 8,3 years. The pre-alcoholization VAS was 85.84 ± 12.00, while at follow-up scored 28.85 ± 31.35, showing a significant decrease improving in 113/125 cases (90.4%). Treatment was considered successful with a reduction of the VAS value superior to 50% in 89 out of 125 patients (71.2%). The mean overall AOFAS score at -up was 85.09 ± 13.41. CONCLUSIONS: Needle-electrode guided percutaneous alcoholization is an outpatient, minimally invasive procedure with low rate of complications. Better results of those obtained with traditional conservative treatments and comparable with those reported with other alcohols injections or surgical nerve excision were observed. LEVEL OF EVIDENCE: Level IV, retrospective case series.

External fixation can be an option for proximal humerus fractures Neer 3-4.

BACKGROUND: Proximal humeral fractures (PHF) account for 4-6% of all fractures and 25% of humeral fractures. While conservative treatment is the gold standard for simple fractures, there is no consensus about the best treatment choice for complex PHF in the elderly. Recently a new external fixator was introduced in clinical practice for treatment of complex PHF.  Aim of the study was to evaluate the functional results of this therapeutic approach. METHODS: Data were retrospectively analyzed. Inclusion criteria were: three- and four- parts PHF according to Neer, treatment with closed reduction and external fixation, normal Abbreviated Mini Mental Test score, independence in the daily living, non-pathological fracture, glenohumeral joint with moderate osteoarthritic changes and availability of clinical and radiological follow-up. For each patient demographic data, comorbidities, surgery time and estimated blood loss were recorded. Clinical and radiological evaluation were performed at 1, 2, 6, 12 months. RESULTS: 17 patients were enrolled. Mean age was 69.7 years. Fractures were classified according to Neer as type III in 10 cases and type IV in 7 cases. The mean operating time was 22 minutes. Mean Constant score value at follow up was 74 ±11,52 at 2 months, 82 ± 11,16 at 6 months and 85 ± 9,86 at 12 months. CONCLUSION: These preliminary results show that the studied system is easy to use, minimally invasive, effective in reducing surgical and hospitalization time. The results in terms of functional recovery are encouraging, showing a reduced number of complications.

Valenti resection arthroplasty for hallux rigidus: A systematic review.

BACKGROUND: Valente Valenti proposed in 1976 a "V" resection of the first metatarsophalangeal joint (MPT1) on the sagittal plane for advanced stages of hallux limitus/rigidus, preserving length of the first ray, flexor hallux brevis and sesamoid function. The available literature concerning correct indications, management and clinical outcomes of the Valenti procedure (VP) and its modifications in patients affected by hallux limitus/rigidus was systematically analyzed. METHODS: Titles and abstracts of all selected articles were independently screened by two authors to assess their suitability to the research focus. RESULTS: Selection produced 8 articles as full-text, for a total of 347 patients, with a mean follow-up of 6±7.1 (range 0.2-17.5) years. Most common complication was transient sesamoiditis in 21 (7.4%) patients. No substantial differences in clinical outcomes were found between the original and modified techniques. CONCLUSIONS: VP appears to allow an early recovery with few complications, if compared to fusion, interposition arthroplasties or osteotomies. The wide joint resection does not prevent, if necessary, further procedures such as fusion or implants. LEVEL OF EVIDENCE: Level I, systematic review.

Post-traumatic cystic lesion following radius fracture: a case report and literature review.

BACKGROUND: Post-traumatic osseous cystic lesions represent a rare complication in children. Usually a post-fracture cyst is a lipid inclusion cyst, which is radiolucent and may be seen adjacent to a healing torus fracture. It is typically asymptomatic and appears just proximal to the fracture line within the area of subperiosteal new bone formation. CASE REPORT: We report a case of post-fracture cyst of the distal radius in an 8 year-old girl with spontaneous resolution. A fat-fluid level within the subperiosteal cystic lesion in MRI is a typical feature of post-traumatic cystic lesion in children. DISCUSSION AND CONCLUSION: MRI or CT scan is sufficient to confirm the diagnosis of post-traumatic cystic lesions without the need for further management other than reassurance and advise that they may occasionally cause discomfort but resolve with time.

Mesenchymal Stem Cells injection in hip osteoarthritis: preliminary results.

BACKGROUND AND AIM OF THE WORK: Osteoarthritis will become even more common in the near future since the average life span is steadily growing. Pain and loss of function are the main complaints reported by patients, inevitably leading towards a worsened daily life performance. New modern techniques have been developed with advanced cell based therapies. Mesenchymal stem cells (MSC) have the inner ability to mature into different types of cells depending on the stimuli they undergo. This technique has already been proven successful in the knee and, with this retrospective study, we would like to assess its feasibility in the hip joint. METHODS: 6 consecutive patients affected by hip osteoarthritis were treated by intra-articular injection of autologous adipose-derived MSC between June 2017 and June 2018. Our study included only patients with constant hip pain resistant conservative treatment and OA graded 0-2 on the Tonnis grading scale. All 6 patients were evaluated in the preoperative setting and at the 6 months post-operative mark. RESULTS: The HHS showed an improvement from the pre-operative baseline mean value of 67.2±3.4 to the 84.6±6.3 post-operative value. Moreover, the WOMAC score dropped from a baseline score of 36.3±4.7 to 19.8±3.4 at 6 months' post-op follow up visit. CONCLUSIONS: MSC Lipogems is a fairly easy technique. No adverse effects were recorded in our experience. Preliminary results showed a positive outcome according to all the grading systems used in this study even though a longer follow up is needed to validate this technique.

Minimally invasive distal first metatarsal osteotomy can be an option for recurrent hallux valgus.

BACKGROUND: Recurrence rate of surgical treatment of hallux valgus ranges in the literature from 2.7% to 16%, regardless of used procedure. In this study, long-term results of a minimally invasive distal osteotomy of the first metatarsal bone for treatment of recurrent hallux valgus are described. METHODS: 32 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 26 patients for treatment of recurrent hallux valgus. Primary surgery had been soft tissue procedures in 8 cases (25%), first metatarsal or phalangeal osteotomies in 19 cases (59.4%) and Keller procedures in 5 cases (15.6%). RESULTS: Patients were assessed with a mean follow-up of 9.8±4.3 years. All patients reported the disappearance or reduction of the pain. The mean overall AOFAS score improved from 46.9±17.8 points to 85.2±14.9 at final follow-up. The mean hallux valgus angle decreased from 26.1±9.1 to 9.7±5.4°, the intermetatarsal angle decreased from 11.5±4.5 to 6.7±4.0°. No major complications were recorded with a re-recurrence rate of 3.1% (1 case). CONCLUSIONS: Percutaneous distal osteotomy of the first metatarsal can be a reliable and safe surgical option in the recurrent hallux valgus with low complication rate and the advantages of a minimally invasive surgery. LEVELS OF EVIDENCE: IV, Retrospective Case Series.

EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages. METHODS: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory. RESULTS: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed. CONCLUSIONS: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Percutaneous distal osteotomy of lesser metatarsals (DMMO) for treatment of metatarsalgia with metatarsophalangeal instability.

BACKGROUND: Clinical and radiological results of percutaneous distal metatarsal minimally invasive osteotomy (DMMO) of the lesser rays for surgical treatment of primary metatarsalgia due to plantar overpressure with metatarsophalangeal instability are described. The aim of this prospective study was to assess the efficacy, feasibility and safety of this minimally invasive surgical (MIS) technique, verifying the possibility to lower the complication rate related to surgical exposures, to reduce operating times with comparable functional and cosmetic results to those reported with traditional open procedures. METHODS: Hundred and six consecutive percutaneous distal osteotomies without fixation (DMMO) of the second, third or fourth metatarsal bones were performed in 57 patients (70ft) with a mean age at the surgery of 60.2 years (30-81) for treatment of metatarsalgia with metatarsophalangeal instability. Patients were clinically assessed with the AOFAS and Coughlin's Scores, the latter classifying the results in relation to the patient's subjective satisfaction. RESULTS: The mean follow-up was of 45.0±13.3months (24-68). All patients reported the disappearance or reduction of the pain that they had experienced prior to the operation around the metatarsal heads. The mean overall AOFAS score improved from 42.7±13.4 points (9-77) to 92.8±8.6 points (44-100) at the time of final follow-up. Patient subjective satisfaction according to Coughlin's classification was excellent in 62ft (88.6%), good in 7ft (10.0%), fair in 0ft and poor in one foot (1.4%). CONCLUSIONS: We consider the percutaneous distal lesser metatarsal osteotomy without fixation (DMMO) a reliable surgical option in metatarsalgia due to metatarsophalangeal instability in early stages as in grade I and II according to Coughlin classification.

CT-guided radiofrequency ablation of osteoid osteoma using a multi-tined expandable electrode system.

BACKGROUND AND AIM OF THE WORK: Radiofrequency ablation (RFA) is the gold standard for the treatment of symptomatic osteoid osteoma (OO) as RFA yields both a high success and low complication rate. It has been widely utilized over the years, but recurrences of OO after this treatment have been documented. These recurrences may be the result of various factors, including incomplete tumor ablation, and are significantly higher in lesions greater than 10 mm. Thus, the need to induce thermal ablation in a wider area led us to use a Multi-Tined Expandable Electrode System (MTEES). In this study we examined the efficacy and safety of RFA using a MTEES in symptomatic OO. METHODS: Between January 2005 and June 2007, 16 patients with symptomatic OO were treated by CT-guided percutaneous RFA using a MTEES. The diameter of OO ranged from 6 to 15 mm (mean 10±2.6 mm). Patients were evaluated for clinical outcomes, complications and recurrence. Pain evaluation was assessed preoperatively, 2 weeks postoperatively and at last follow-up. RESULTS: Clinical follow-up was available for all patients at a mean of 84.3 months (range 73-96 months). Mean preoperative VAS score was 7.4 (range 5-9), two weeks after the procedure mean VAS score was 0.3 (range 0-1) with a mean change of -7.06 points (p<0.0001). At the last follow-up a complete relief from pain has been observed in all patients. No major and minor complications were observed nor recurrences. CONCLUSIONS: RFA using a MTEES has been effective, safe and reliable for the treatment of OOs. This system, by increasing the size of the necrosis, could be a viable alternative to the single needle electrode in lesions larger than 10 mm, reducing the risk of recurrence.

A pseudotumoral lesion diagnosed for a hypertrofic fibrosis at the proximal stump in anterior tibialis tendon missed rupture: a case report.

The Anterior Tibialis is the most important muscle in ankle dorsiflexion. The anterior tibialis tendon (ATT)'s rupture is an infrequent condition which can be both traumatic and spontaneous. Clinic is poor and it is necessary to confirm the suspect by US or MRI. The reported case refers to a 40 years old man who had a direct trauma at ankle and midfoot which was originally conservatively treated for an ankle sprain. Three months later he returned with pain, swelling and paresthesia. MRI was performed showing a neoformation in the contest of ATT's rupture. The patient underwent open excisional biopsy which was diagnostic for hypertrofic fibrosis. After two weeks, the symptoms were completely decreased and patient didn't want to undergo surgery for tendon reconstruction because he had no limitation in daily activity life.

Antimicrobial activity of gentamicin and vancomycin combination in joint fluids after antibiotic-loaded cement spacer implantation in two-stage revision surgery.

Gentamicin (G) and vancomycin (V) concentrations in joints fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision for infected arthroplasty, and the inhibitory activity of joint fluids against different multiresistant clinical isolates were studied. A total of 12 patients undergoing two-stage revision surgery with implantation of industrial G spacers added with different amounts of V was studied. Serum and joint fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and joint bactericidal titer (JBT) of combination were determined against multiresistant staphylococcal strains. The local release of G and V from PMMA cement seemed prompt and effective. Serum levels were below the limit of detection. The same joint fluid showed different activity according to the susceptibility of the pathogens tested. Gentamicin and V were released from spacers at bactericidal concentrations exerting a strong inhibition against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) strains.

The pathogenesis of Achilles tendinopathy: a systematic review.

Achilles tendinopathy is a degenerative, not an inflammatory, condition. It is prevalent in athletes involved in running sports. A systematic literature review on Achilles tendon tendinopathy has been performed according to the intrinsic (age, sex, body weight, tendon temperature, systemic diseases, muscle strength, flexibility, previous injuries and anatomical variants, genetic predisposition and blood supply) and extrinsic risk factors (drugs and overuse), which can cause tendon suffering and degeneration. Different theories have been found: Neurogenic, Angiogenic, Impingement and "Iceberg" Hypotheses. Multiple databases were utilized for articles published between 1964 and 2013. The different hypothesis were analyzed, differently considering those concerning the pathogenesis of tendinopathy and those concerning the etiology of complaints in patients. This review of the literature demonstrates the heterogeneity of Achilles tendinopathy pathogenesis. Various risk factors have been identified and have shown an interaction between them such as genes, age, circulating and local cytokine production, sex, biomechanics and body composition.